What is the recommended first-line analgesic for a pregnant patient at term experiencing headaches?

Recommended Analgesic for Headache in Pregnant Patient at Term

Acetaminophen (paracetamol) 1000 mg is the first-line analgesic for headache treatment in pregnant patients at term, including those in the third trimester. 1

First-Line Treatment

• Acetaminophen 1000 mg is the preferred acute treatment throughout pregnancy due to its relatively safe profile, with the strongest evidence supporting its use at term. 1
• The recommended dose is 1000 mg, which can be administered orally or as a suppository for better absorption if nausea is present. 1, 2
• The FDA drug label advises asking a health professional before use during pregnancy, but extensive clinical experience supports its safety profile. 3

Critical Medications to Avoid at Term

• NSAIDs (ibuprofen, naproxen) are absolutely contraindicated in the third trimester due to risks of premature closure of the ductus arteriosus, oligohydramnios, and bleeding complications. 1
• NSAIDs can only be used during the second trimester if acetaminophen fails, but must be discontinued before the third trimester begins. 1
• Opioids and butalbital-containing medications should never be used due to risks of dependency, rebound headaches, neonatal withdrawal, and potential fetal harm. 1
• Ergotamine derivatives and dihydroergotamine are contraindicated throughout pregnancy due to oxytocic properties that can harm the fetus. 1

Second-Line Options at Term (When Acetaminophen Fails)

• Metoclopramide 10 mg can be used for migraine-associated nausea and provides direct analgesic effects through central dopamine receptor antagonism, and is safe in the second and third trimesters. 1
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly and is unlikely to be harmful during pregnancy. 1, 2
• Sumatriptan may be used sporadically under strict specialist supervision when acetaminophen and antiemetics fail, with most safety data relating specifically to sumatriptan among the triptans. 1

Important Clinical Considerations

• Before prescribing any medication, rule out preeclampsia: A new headache in a pregnant woman at term with hypertension should be considered part of preeclampsia until proven otherwise and requires urgent evaluation. 1
• New onset headache or headache with neurologic signs, progressive symptoms, or severe/different characteristics requires immediate cerebral and cerebrovascular imaging and blood pressure monitoring. 1
• Non-pharmacological interventions should always accompany medication: adequate hydration, regular meals, consistent sleep patterns, identifying and avoiding triggers, quiet dark environment, ice packs, and relaxation techniques. 1

Practical Algorithm for Term Pregnancy

1. First attempt: Acetaminophen 1000 mg orally (or suppository if vomiting) 1
2. If nausea present: Add metoclopramide 10 mg for synergistic analgesia 1
3. If severe/refractory: Consider sumatriptan under specialist supervision only after other options fail 1
4. Never use: NSAIDs, opioids, butalbital, ergots, or CGRP antagonists at term 1

Post-Delivery Considerations

• Paracetamol remains the preferred medication immediately postpartum, while ibuprofen and sumatriptan become safe options during breastfeeding. 1
• Treatment options become less restrictive during lactation compared to pregnancy. 4